Hemostatic clip with needle passer

ABSTRACT

A device for treating a tissue opening includes a proximal portion including an elongated flexible member, a capsule releasably coupled to a distal end of the flexible member and including a lumen extending therethrough and a clip including a pair of arms movably housed within the capsule. A suture extending along a first one of the pair of arms and including a loop at a distal end thereof extending across an opening extending through the first one of the pair of arms. A suture grabbing element extending laterally from a second one of the pair of arms and including a hook so that, when the pair of arms are moved toward a closed configuration, the hook extends through the opening to grab the loop and draw the distal end of the suture from the first one of the pair of arms toward the second one of the pair of arms.

PRIORITY CLAIM

The present application is a Continuation of U.S. patent applicationSer. No. 16/824,410 filed on Mar. 19, 2020; which is a Continuation ofU.S. patent application Ser. No. 15/842,489 filed on Dec. 14, 2017, nowU.S. Pat. No. 10,631,872; which is a Continuation of U.S. patentapplication Ser. No. 14/788,021 filed on Jun. 30, 2015, now U.S. Pat.No. 9,877,732; which claims priority to U.S. Provisional ApplicationSerial No. 62/019,588 filed on Jul. 1, 2014. The disclosure of the abovepatent(s)/application(s) is incorporated herein by reference.

BACKGROUND

Physicians have become more willing to perform more aggressiveinterventional and therapeutic endoscopic procedures including, forexample, removal of larger lesions (e.g., cancerous masses), tunnelingunder mucosal layers in the gastro-intestinal (GI) tract to treattissues below the mucosa, full thickness removal of tissue, insertingdevices through the GI tract and then penetrating the GI organ to treattissue outside the GI tract, and endoscopic treatment/repair ofpost-surgical issues (e.g., post-surgical leaks, breakdown of surgicalstaple lines, anastomotic leaks). These procedures may increase the riskof perforating the wall of the GI tract, or may require closure of theGI tract wall as part of the procedure. Endoscopic closure reduces costand may reduce the trauma and inconvenience associated with theseprocedures. However, conventional tissue closure devices may beinsufficient to close certain perforations.

SUMMARY

The present disclosure relates to a device for treating a tissueopening, comprising a proximal portion including an elongated flexiblemember, a capsule releasably coupled to a distal end of the flexiblemember, the capsule extending longitudinally from a proximal end to adistal end and including a lumen extending therethrough, and a clipincluding a pair of arms movably housed within the lumen of the capsulesuch that the pair of arms are movable between an open configuration anda closed configuration, the pair of arms being biased toward the openconfiguration such that when the pair of arms are moved distally withrespect to the capsule, distal ends of the pair of arms are separatedfrom one another to receive target tissue therebetween. The device alsocomprises a suture extending along a first one of the pair of arms andincluding a loop at a distal end thereof, the loop extending across anopening extending laterally through the first one of the pair of armsand a suture grabbing element extending laterally from a second one ofthe pair of arms toward the first one of the pair of arms and includinga hook so that, when the pair of arms are moved toward the closedconfiguration, the hook extends through the opening in the first one ofthe pair of arms to grab the loop extending across the opening to drawthe distal end of the suture from the first one of the pair of armstoward the second one of the pair of arms.

In an embodiment, the first one of the pair of arms may include a notchin communication with the opening so that the loop is received withinthe notch to extend across the opening.

In an embodiment, the notch may extend one of along an interior surfaceof the first one of the pair of arms and proximally from a distal edgeof the first one of the pair of arms.

In an embodiment, the device may further comprise a control memberconnected to the pair of arms for moving the pair of arms between theopen configuration and the closed configuration.

In an embodiment, the device may further comprising a locking mechanismfor locking the pair of arms in the capsule in the closed configuration.

In an embodiment, the capsule may include a wedge feature wedging thesuture between the wedge feature and a portion of one of the pair ofarms, when the arms are locked within the capsule, so that the suture isrestrained from distal translation.

In an embodiment, the capsule may further include a cutting featurecutting a portion of the suture extending proximally of a wedged portionof the suture.

In an embodiment, the first one of the pair of arms may include a secondopening and the second one of the pair of arms includes a wedge elementextending laterally therefrom toward the first one of the pair of armsso that, when the pair of arms are locked within the capsule, the wedgeelement extends through the second opening to wedge the suture betweenthe wedge element and an edge of the second opening.

The present disclosure also relates to a device for treating a tissueopening, comprising a proximal portion including an elongated flexiblemember, a capsule releasably coupled to a distal end of the flexiblemember, the capsule extending longitudinally from a proximal end to adistal end and including a lumen extending therethrough and a clipincluding pair of arms movably housed within the lumen of the capsulesuch that the pair of arms are movable between an open configuration anda closed configuration, the pair of arms being biased toward the openconfiguration such that when the pair of arms are moved distally withrespect to the capsule, distal ends of the pair of arms are separatedfrom one another to receive target tissue therebetween. The device alsocomprises a needle extending from a first end pivotally connected to afirst one of the pair of arms via a releasable connection to a secondend, the needle pivotal relative to the first one of the pair of armsbetween an insertion configuration, in which the second end is movedtoward the first one of the pair of arms, and a firing position, inwhich the second end extends laterally toward a second one of the pairof arms, so that, when the pair of arms are moved toward the closedconfiguration in the firing position, the needle engages an engagingfeature along a second one of the pair of arms, the releasableconnection releasing when the pair of arms are moved toward the openconfiguration after the needle has engage the engaging feature and asuture extending through a portion of the device such that a distal endthereof is connected to the needle.

In an embodiment, the needle may be curved along a length thereof.

In an embodiment, the engagement feature may include a longitudinalrecess extending through a portion of the second one of the pair of armsand retaining tabs extending over a portion thereof to preventdisengagement of the needle therefrom once the needle has been receivedtherein.

In an embodiment, the engagement feature may further include a curvedsurface extending along a distal portion of the longitudinal recess forguiding the needle thereinto.

In an embodiment, the device may further comprise a control memberconnected to the pair of arms for moving the pair of arms between theopen configuration and the closed configuration.

In an embodiment, the device may further comprise a locking mechanismfor locking the pair of arms in the closed configuration.

In an embodiment, the capsule may include a wedge feature along aninterior surface thereof for locking the suture relative to the clipwhen the clip is in a locked configuration and a cutting feature forcutting a portion of the suture proximal of a wedged portion of thesuture.

The present disclosure also relates to a method for treating a tissueopening, comprising inserting a clip to a target area within a patientbody, the clip including a pair of arms movable between an openconfiguration in which distal ends of the pair of arms are separatedfrom one another and a closed configuration in which distal ends of thepair of arms are drawn toward one another to grip tissue receivedtherebetween, and a suture extending along a first one of the pair ofarms and including a loop at a distal end thereof, the loop extendingacross an opening extending laterally through the first one of the pairof arms, positioning the pair of arms over a first portion of tissuealong a tissue opening with the clip in the open configuration such thatthe first portion of tissue is received between the distal ends of thepair of arms, moving the clip toward the closed configuration so that ahook of suture grabbing element extending laterally from a second one ofthe pair of arms extends through the first portion of tissue and intothe opening in the first one of the pair of arms to grab the loopextending across the opening, and moving the pair of arms to the openconfiguration such that the suture grabbing element is retracted fromthe first portion of tissue so that the suture is passed through thefirst portion of tissue.

In an embodiment, the method may further comprise, after moving the pairof arms to the open configuration with the suture passed through thefirst portion of tissue, positioning the pair of arms over a secondportion of tissue along the tissue opening substantially opposing thefirst portion with the clip in the open configuration with the secondportion of tissue is received between the distal ends of the pair ofarms and moving the pair of arms to the closed configuration such thatthe pair of arms grip the second portion of tissue between distal endsof thereof.

In an embodiment, the method may further comprise pulling the sutureproximally relative to the clip to draw the first portion of tissuetoward the second portion of tissue.

In an embodiment, the method may further comprise locking the clip inthe closed configuration.

In an embodiment, locking the clip may include locking the suturerelative to the clip and cutting a portion of the suture extendingproximally from the clip.

BRIEF DESCRIPTION

FIG. 1 shows a perspective view of a device according to an exemplaryembodiment of the present disclosure, in a first configuration;

FIG. 2 shows another perspective view of the device of FIG. 1 , a clipof the device gripping a first portion of tissue of a tissue opening;

FIG. 3 shows another perspective view of the device of FIG. 1 , in asecond configuration;

FIG. 4 shows a side view of the device of FIG. 1 , the clip gripping asecond portion of tissue of the tissue opening;

FIG. 5 shows a perspective view of the device of FIG. 1 , with the firstand second tissue portions drawn toward one another;

FIG. 6 shows another perspective view of the device of FIG. 1 , in alocked configuration;

FIG. 7 shows a longitudinal cross-sectional view of a distal portion ofthe device of FIG. 1 , in an unlocked configuration;

FIG. 8 shows a longitudinal cross-sectional view of the distal portionof the device of FIG. 1 , in a locked configuration;

FIG. 9 shows a perspective view of arms of the clip of the device ofFIG. 1 , including a needle; and

FIG. 10 shows a perspective view of arms of a clip according to analternate embodiment of the device of FIG. 1 ;

FIG. 11 shows a longitudinal side view of a device according to anotherexemplary embodiment in a first configuration;

FIG. 12 shows a longitudinal side view of the device of FIG. 11 , in asecond configuration;

FIG. 13 shows a longitudinal side view of the device of FIG. 11 , in athird configuration;

FIG. 14 shows a perspective view of a clip of the device of FIG. 11 ;

FIG. 15 shows another perspective view of the clip of the device of FIG.11 ;

FIG. 16 shows a longitudinal side view of the device of FIG. 11 ,according to a further embodiment;

FIG. 17 shows a perspective view of a device according to an alternateembodiment;

FIG. 18 shows a longitudinal cross-sectional view of the device of FIG.17 ;

FIG. 19 shows a perspective view of a clip according to anotherexemplary embodiment;

FIG. 20 shows a perspective view of a clip according to yet anotherexemplary embodiment;

FIG. 21 shows a perspective view of another exemplary embodiment;

FIG. 22 shows a partially transparent side view of a device according toanother exemplary embodiment in a preloaded insertion configuration;

FIG. 23 shows a perspective view of the device of FIG. 22 , in a firingposition;

FIG. 24 shows transparent side view of the device of FIG. 22 ;

FIG. 25 shows another transparent side view of the device of FIG. 22 ;

FIG. 26 shows yet another transparent side view of the device of FIG. 22;

FIG. 27 shows a perspective view of the device of FIG. 22 ;

FIG. 28 shows a portion of a clip according to another exemplaryembodiment;

FIG. 29 shows a perspective view of a portion of a clip according to yetanother exemplary embodiment;

FIG. 30 shows a transparent side view of the portion of the clip of FIG.29 ;

FIG. 31 shows a partially transparent perspective view of a deviceaccording to another exemplary embodiment; and

FIG. 32 shows a partially transparent perspective view of a deviceaccording to yet another exemplary embodiment.

DETAILED DESCRIPTION

The present disclosure may be further understood with reference to thefollowing description and the appended drawings, wherein like elementsare referred to with the same reference numerals. The present disclosurerelates to devices for tissue closure and, in particular, to anendoscopic tissue closure device. Exemplary embodiments of the presentdisclosure describe an endoscopic tissue closure device comprising aclip and a suture. The suture may be passed through a first portion oftissue along a tissue opening and the clip may be applied over a secondportion of tissue along the tissue opening substantially opposing thefirst portion so that the first portion of tissue may be drawn towardthe second portion by drawing the suture proximally relative to theclip. It should be noted that the terms “proximal” and “distal” as usedherein, are intended to refer to a direction toward (proximal) and awayfrom (distal) a user of the device.

As shown in FIGS. 1-10 , a device 100 according to an exemplaryembodiment of the present disclosure comprises a clip 102 includingfirst and second arms 104, 106 movable between an open configuration anda closed configuration and a needle 108 extending laterally inward fromthe first arm 104 toward the second arm 106 to pass a suture 112 coupledto the needle 108 through a first portion of tissue 12 along a tissueopening 10. The device is inserted to a target spot within the body via,for example, a body lumen accessed via a naturally occurring bodilyorifice. The device 100, however, may be inserted into the patient bodyin any of a number of different ways such as, for example, via aflexible endoscope, or through a rigid tube, etc. The clip 102 ismovable between a closed configuration in which the first and secondarms 104, 106, respectively, are drawn together in contact with oneanother and an open configuration in which distal ends 114, 115 of thefirst and second arms 104, 106, respectively, are separated from oneanother to permit a portion of tissue to be received therebetween. Inthe closed configuration, the distal ends 114, 115 of the arms 104, 106are drawn toward one another to grip tissue received therebetween. Thesecond arm 106 includes an opening 110 such as a slot or hole extendinglaterally therethrough. The opening 110 is sized and shaped to receive aportion of the needle 108 therein. The needle 108 is attached to thefirst arm 104 via a frangible link 116 such that when the arms 104, 106are moved toward the closed configuration over the first portion oftissue 12, the needle 108 is passed through the first portion of tissue12 into the opening 110 and locked therein so that when the clip 102 ismoved once again to the open configuration, the frangible link 116 isbroken leaving the needle 108 lodged in the second arm 110. As the clip102 moves to the open configuration, the suture 112 is drawn through thefirst portion of tissue 12. The clip 102 is then opened and repositionedover a second portion of tissue 14 (e.g., a second portion of tissue onthe periphery of the tissue opening 10 substantially opposite the firstportion 12). Once the clip 102 has been repositioned as desired, theclip 102 is moved to the closed configuration to grip the second portionof tissue 14. The loop of suture 112 is then tightened to draw the firstportion of tissue 12, through which the suture 112 is passed, toward theclip 102 until the first portion 12 is drawn against the second portion14 closing the tissue opening 10.

The clip 102 may further include a capsule 118 in which the first andsecond arms 104, 106 are movably housed. The capsule 118 extendslongitudinally from a proximal end 124 to a distal end 126 and includesa lumen 128 extending therethrough. Proximal ends of the first andsecond arms 104, 106 are slidably received within the lumen 128 so thatthe clip 102 may be moved between the open and the closedconfigurations. The first and second arms 104, 106 may be biased towardthe open configuration such that when the first and second arms 104, 106are moved distally out of the capsule 118, distal ends 114, 115 of thearms 104, 106 extend away from one another to the open configuration.When the first and second arms 104, 106 are drawn proximally into thecapsule 118, however, the first and second arms 104, 106 are constrainedvia an interior surface 132 of the capsule 118 so that distal ends 114,115 of the arms 104, 106 are drawn toward one another into the closedconfiguration. Distal ends 114, 115 may include gripping features suchas, for example, teeth or tines extending laterally inward for grippingthe tissue received therebetween. The clip 102 may be coupled to aproximal portion of the device 100, not shown, via a control member orother device which permits a user to move the clip 102 proximally anddistally relative to the capsule 118 so that the clip 102 moves betweenthe open and closed configurations.

In one embodiment, the capsule 118 may be coupled to a handle assembly(not shown), which remains outside of a patient body, via a flexiblemember to facilitate insertion of the clip 102 to a target area withinthe patient body through even tortuous paths of the body. The arms 104,106 are moved with respect to the capsule 118 via the control membercoupled to a proximal end of the arms 104, 106 and extending proximallythrough the flexible member to the handle assembly. The arms 104, 106may be moved distally and proximally with respect to the capsule 118between the open and closed configurations by moving the control memberdistally and proximally, respectively, via an actuator of the handleassembly. Once in the closed configuration, the control member may bedrawn further proximally to lock the clip 102 in the closedconfiguration and disengage the clip 102 from the proximal portion ofthe device 100. For example, the clip 102 may be locked in the closedconfiguration by engagement between a portion of the clip 102 and alocking feature of the capsule 118 and disengaged from the proximalportion of the device by the separation of a frangible linksubstantially as described in U.S. Pat. No. 7,494,461 issued on Feb. 24,2009 to Wells et al. In particular, when the control member of thisembodiment is drawn proximally after a point of maximum proximalwithdrawal of the clip 102 into the capsule 118, increased tension onthe control member causes disengagement of the control member from thearms 104, 106, causing a bushing which connects the capsule 118 to theflexible member to become disengaged therefrom. The structural featuresof the clip 102, however, are not limited to those described in U.S.Pat. No. 7,494,461 and that the clip 102 may be deployed in the body inany of a number of ways via the further proximal motion of the controlmember with respect to the clip 102.

As shown in FIGS. 7-8 , the clip 102 further includes a wedge feature130 which wedges a portion of the suture 112 within the capsule 118. Forexample, the suture 112 may be wedged between one of the arms 104, 106and the interior surface 132 of the capsule 118, when the clip 102 is inthe locked configuration. A distal portion of the capsule 118 may besized and shaped such that when the arms 104, 106 are drawn into thelocked configuration, the arms 104, 106 and the capsule 118 form afriction fit with the portion of the suture 112 received therebetweenlocked therein. The capsule 118 may further include a cutting feature119 along the interior surface 132 thereof for cutting a portion of thesuture 112 extending proximally from the wedge. The cutting feature 119of this embodiment is positioned on a portion of the capsule 118proximal of the wedge feature. The cutting feature 119 may include, forexample, a sharpened protrusion extending laterally inward and distallyfrom the interior surface 132 of the capsule 118.

The needle 108 extends from a first end 120 attached to the first arm104 via the frangible link 116 to a second end 122 extending laterallyfrom the first arm 104 toward the second arm 106. The frangible link 116may include, for example, a tight friction fit between the needle 108and an opening in the first arm 104, an adhesive, weld, or solder jointdesigned to fail when subject to a force exceeding a predeterminedthreshold level. The frangible link 116 may include any of a variety ofcoupling mechanisms so long as the frangible link 116 fails when subjectto a force exceeding the predetermined threshold level. Although thisexemplary aspect is described and shown as including a frangible link116 connecting the needle 108 to the first arm 104, the needle 108 mayalternatively be connected to the first arm 104 via a releasablecoupling. For example, the needle 108 may releasably engage a needleengaging feature in the first arm 104. The needle 108 may be releasedfrom this needle engaging feature via a force applied to the needle 108.The force may be, for example, a torsional force applied to the needle108 by the second arm 106, which causes the needle 108 to rotate out ofengagement with the needle engaging feature. Alternatively, the needle108 may be actively released from the first arm 104, for example, by theuser by means of a trigger mechanism of the like.

As shown in FIG. 9 , a portion of the needle 108 includes barbs 134therealong so that when the needle 108 is received within the opening110 extending laterally through the second arm 106, the needle 108engages the opening 110 so that the needle 108 is locked therewithin. Inanother embodiment, as shown in FIG. 10 , the barb features 134′ may beincluded in the opening 110′ so that when the needle 108′ is receivedtherewithin, the opening 110′ engages a groove 136′ or othercorresponding feature of the needle 108′. Although the exemplaryembodiments describe barbs, the needle 108 and the opening 110 of thesecond arm 106 may include any of a variety of corresponding lockingfeatures so long as the needle 108 is locked within the opening 110 whenreceived therein.

The suture 112 extends from a distal end 120 connected to the needle 108to a proximal end (not shown) extending proximally through the capsule118 and the proximal portion of the device 100 to the handle assembly.The suture 112 is slidably received within the capsule 118 so that thesuture 112 may be slackened and tightened, as desired. The proximal endof the suture 112 may be coupled to an actuating feature of the handleassembly so that the suture 112 may be tightened via the actuatingfeature on the handle assembly. Alternatively, the proximal end of thesuture 112 may extend from the handle assembly so that the user may drawthe proximal end proximally with respect to the device 100 to tightenthe suture 112. The distal end 120 of the suture 112 should be connectedto a portion of the needle 108 between the locking feature (e.g., barbs)of the needle 108 and the first end 120 so that locking the needle 108within the opening 110 does not interfere with the slackening andtightening of the suture 112.

According to a method using the device 100, the clip 102, with theneedle 108 connected to the first arm 104, is inserted to a target areain the patient body through, for example, a working channel of anendoscope. The clip 102 may be inserted through the working channel inan insertion configuration with the handle assembly remaining outsidethe patient's body. In this insertion configuration, the first andsecond arms 104, 106 are drawn toward one another with the needle 108connected to the first arm 104. The needle 108, however, is preventedfrom engaging the second arm 106. Once the clip 102 has reached thetissue opening 10 to be closed, the clip 102 is moved to the openconfiguration by moving the clip arms 104, 106 distally with respect tothe capsule 118 so that the arms 104, 106 are permitted to revert totheir biased open position, as shown in FIG. 1 . In the openconfiguration, the arms 104, 106 are positioned so that the firstportion of tissue 12 may be received therebetween.

Once positioned, as desired, the clip 102 is moved to the closedconfiguration to grip the first portion of tissue 12 between arms 104,106 by drawing the clip arms 104, 106 into the capsule 118 so that thearms 104, 106 are constrained thereby. As the clip 102 is moved to theclosed configuration, as shown in FIG. 2 , the needle 108 extendinglaterally from the first arm 104 passes through the first portion oftissue 12 and engages the opening 110 of the second arm 106. Prior tothe needle 108 engaging the opening 110 of the second arm 106, however,the arms 104, 106 may be moved between the open and closed positions toadjust the placement of the arms 104, 106 over tissue, as desired. Thismovement may be controlled by a user interface having incrementalclosing positions controlled to prevent premature engagement of theneedle 108 or via tactile features that have threshold forces to actuatebetween states. Once the needle 108 has engaged the opening 110 of thesecond arm 106, however, the clip 102 is moved to the open configurationso that distal ends 114, 115 of the arms 104, 106 are once againseparated from one another. Since the needle 108 is locked within theopening 110 of the second arm 106, the separation of the distal ends114, 115 causes the frangible link 116 connecting the first end 120 ofthe needle 108 to the first arm 104 to break. The needle 108, however,remains locked in the opening 110 so that the suture 112 is passedthrough the first portion of tissue 12. As the clip 102 is moved to theopen configuration, the clip 102 is also moved proximally relative tothe first portion of the tissue 12, causing the clip 102 to be movedproximally with respect to the suture 112, such that a slack in thesuture 112 is formed, as shown in FIG. 3 .

The clip 102 is then moved to the second portion of tissue 14substantially opposing the first portion 12 and positioned thereoversuch that the second portion 14 is received between the arms 104, 106.As shown in FIG. 4 , once the clip 102 has been positioned over thesecond portion, as desired, the clip 102 is moved to the closedconfiguration to grip the second portion of tissue 14 between the arms104, 106. The suture 112 is then drawn proximally with respect to theclip 102, drawing the first portion of tissue 12 toward the secondportion of tissue 14 to close the tissue opening 10, as shown in FIG. 5. Although the exemplary embodiments show and describe the clip 102 asbeing moved to the locked configuration once the clip 102 has beenclipped over the second portion of tissue 14 and the first portion ofthe tissue 12 has been drawn theretoward via the suture 112, the clip102 may be repositioned prior to locking, if so desired. For example,clip arms 104, 106 may be repositioned to get a better grasp of thesecond portion of tissue 14.

In another example, the clip 102 may be repositioned to extend over boththe first and second portions of tissue 12, 14, once the first andsecond portions of tissue 12, 14 have been drawn toward one another, sothat the clip 102 grips both portions of tissue 12, 14. Once the tissueopening 10 is closed, as desired, the clip 102 may be locked, as shownin FIG. 6 , by drawing the control member further proximally withrespect to the clip 102. As described above, moving the clip 102 to thelocked configuration will also cause a portion of the suture 112 tobecome wedged between one of the clip arms 104, 106 and the interior ofthe capsule 118. Upon wedging of the suture 112 between the clip arms104, 106, a portion of the suture extending proximally of the wedge iscut therefrom via the cutting feature along the interior of the capsule118. The proximal portion of the device 100 is then removed from thebody such that only the clip 102, the needle 108, and a distal portionof the suture 112 remain within the body to hold the tissue opening 10in the closed position.

As shown in FIGS. 11 to 15 , a device 200 according to another exemplaryembodiment of is substantially similar to the device 100 describedabove, comprising a clip 202 including first and second arms 204, 206movable between an open configuration and a closed configuration via,for example, a capsule 218 slid longitudinally thereover as describedabove in regard to the device 100. Rather than a needle for passing asuture 212 from the first arm 204 to the second arm 206, however, thesuture 212 extends along a portion of the first arm 204 so that a suturegrabbing element 208 extending laterally inward from the second arm 206hooks a portion of the suture 212 as the clip 202 is moved toward theclosed configuration. In use, the clip 202 is positioned in the openconfiguration over tissue (e.g., along a first side of a tissue opening)so that a first portion of tissue along the first side is receivedbetween the first and second arms 204, 206. The clip 202 may then bemoved toward the closed configuration so that the suture grabbingelement 208 pierces the portion of tissue received between the first andsecond arms 204, 206 as the suture grabbing element 208 is moved towardthe first arm 204. A hook feature 236 at an end 222 of the suturegrabbing element 208 interfaces with a portion of the first arm 204 tohook a loop 213 of the suture 212 extending along the first arm 204. Theclip 202 is once again moved to the open configuration so that thesuture grabbing element 208, with the suture 212 hooked thereto, isremoved from the first portion of tissue, passing the suture 212 throughthe first portion of tissue in the process. Similarly to the device 100,after passing the suture 212 through the first portion of tissue, theclip 202 may then be positioned over a second portion of tissue (e.g.,along a second side of the tissue opening) so that the second portion oftissue is received between the first and second arms 204, 206. Once theclip 202 has been repositioned, as desired, the clip 202 is moved to theclosed configuration to grip the second portion of tissue. The suture212 is then tensioned to draw the first portion of tissue, through whichthe suture 212 has been passed, toward the second portion of tissue,thereby closing the tissue opening.

The clip 202 is substantially similar to the clip 102, described aboveexcept as specifically noted. In particular, the clip 202 may, forexample, be biased toward the open configuration so that, when the firstand second arms 204, 206 are moved distally out of the capsule 218, thefirst and second arms 204, 206 extend away from one another toward theopen configuration. When the first and second arms 204, 206 are drawnproximally into the capsule 218, however, the first and second arms 204,206 are constrained via an interior surface of the capsule 218 towardthe closed configuration. In one embodiment, the capsule 218 may becoupled to a handle assembly, which remains outside of a patient body,via a flexible member to facilitate insertion of the clip 202 to atarget within the patient body. The clip 202 may be moved between theopen and closed configuration by moving a control member coupled to aproximal end of the first and second arms 204, 206 via an actuator ofthe handle assembly, as described above in regard to the clip 102. Oncein the closed configuration, the control member is drawn furtherproximally to lock the clip 202 in the closed configuration anddisengage the clip 202 from a proximal portion of the device 200, asdescribed with respect to the device 100.

The first arm 204 of the clip 202, however, includes a notch 240 alongan interior surface 242 of the first arm 204 at a distal end 214thereof. The first arm 204 also includes a slot 210 extending laterallythrough the distal end 214 thereof in communication with the notch 240.In other words, the slot 210 extends through the first arm 204 andthrough the notch 240 so that, when a loop 213 of the suture 212 ishooked on the notch 240, a portion of the loop 213 extends across theslot 210. Thus, the suture grabbing element 208 passes through the slot210, between opposing sides of the notch 240, to hook a portion of theloop 213. The first arm 204 may further include an opening 244 extendinglaterally therethrough, the opening 244 separated from the slot 210 by asmall distance.

In this embodiment, a length of the suture 212 extends from a proximalend coupled to an actuating feature of the handle assembly through theflexible member and the capsule 218 along an exterior surface 246 of thefirst arm 204. Once the suture 212 reaches the opening 244, however, thesuture 212 is fed through the opening 244 so that a remaining distallength of the suture 212 extends along the interior surface 242 of thefirst arm 204 to be hooked via the loop 213 at its distal end 248. Theloop 213 of the suture 212 is hooked by opposing sides of the notch 240so that a portion of the loop 213 extends across the slot 210. Thus,when the suture grabbing element 208 is passed through the slot 210, thesuture grabbing element 208 passes through the loop 213 to grab aportion thereof, hooking the loop 213.

The second arm 206 is substantially similar to the second arm 106 of theclip 102 except as specifically noted below. In contrast to the clip102, the second arm 206 includes the suture grabbing element 208extending laterally from a first end 220 connected to the second arm 206to a second end 222 extending toward the first arm 204. The second end222 includes a hooked recess 236 therein. The second end 222 may alsoinclude an angled surface 223 configured so that, as the suture grabbingelement 208 is inserted through the slot 210, the loop 213 of the suture212 is guided along the angled surface 223 until the loop 213 reachesthe hooked recess 236 and is received therein. The suture grabbingelement 208 is positioned along the second arm 206 so that, when theclip 202 is moved toward the closed configuration, at least a portion ofthe suture grabbing element 208 is received within the slot 210 so thatthe hooked recess 236 hooks the loop 213 of the suture 212 hooked viathe notch 240. The second end 222 may also include an angled surface 223configured so that, as the suture grabbing element 208 is insertedthrough the slot 210, the loop 213 of the suture 212 is guided along theangled surface 223 until the loop 213 reaches the hooked recess 236 andis received therein. The hooked recess 236 is shaped so that, uponhooking the loop 213, the suture 212 is prevented from being unhookedfrom the hooked recess 236.

The device 200 may be used in a manner substantially similar to thedevice 100. Rather than passing the suture 212 through the first portionof tissue via a needle, however, the suture is passed through the firstportion of tissue via the suture grabbing element 218. In particular,the clip 202 is positioned along the first portion of tissue (e.g.,along a first side of a tissue opening) in the open configuration withthe first portion of tissue received between the first and second arms204, 206. The clip 202 is then moved toward the closed configuration sothat the suture grabbing element 208 extends through the first portionof tissue, between opposing sides of the notch 240 into the slot 210 tohook the loop 213 of the suture 212 via the hooked recess 236. Once theloop 213 has been hooked via the hooked recess 236, the clip 202 ismoved toward the open configuration so that the suture grabbing element208, with the suture 212 hooked therethrough, is removed from the firstportion of tissue. Removal of the suture grabbing element 208 from thefirst portion of tissue draws the suture 212 through the first portionof tissue so that the distal end 248 of the suture 212 is now attachedto the second arm 206.

The clip 202 is then be moved toward a second portion of tissue (e.g.,along a second side of the tissue opening) until the second portion oftissue is received between the first and second arms 204, 206 in theopen configuration. Opening of the first and second arms 204, 206 andmoving the clip 202 toward the second side of the tissue opening createsslack in the suture 212 so that a length of the suture 212 extendsacross the tissue opening. The clip 202 may then be moved toward theclosed configuration to grip the second portion of tissue between thefirst and second arms 204, 206. Once the second portion of tissue hasbeen gripped, as desired, the suture 212 is tensioned by drawing thesuture 212 proximally relative to the clip 202. Tensioning the suture212 draws the first portion of tissue, through which the suture 212 ispassed, toward the second portion of tissue to close the tissue opening.Once the tissue opening is closed, the clip 202 may be locked by drawingthe clip arms 204, 206 further proximally into the clip 202. Asdescribed above in regard to the device 100, a wedge feature along aninterior of the capsule 218 may wedge the suture 212 between the firstarm 204 and the capsule 218 while a cutting feature cuts a portion ofthe suture 212 extending proximally from the wedge. Similarly to thedevice 100, locking the clip 202 in the closed configuration deploys theclip 202—and a distal portion of the suture 212—in the body.

According to a further embodiment, as shown in FIG. 16 , the device 200further comprises a longitudinal extension 252 extending from a distalend 226 of the capsule 218. The longitudinal extension 252 is sized andconfigured to interface with the suture grabbing element 208, as theclip 202 is moved toward the locked configuration. In particular, as theclip 202 is moved toward the locked configuration, the suture grabbingelement 208 comes into contact with the longitudinal extension 252.Further proximal motion of the first and second arms 204, 206 relativeto the capsule 218 forces the suture grabbing element 208 to bend towardthe first arm 204, reducing the risk of the suture grabbing element 208causing damage to surrounding tissue upon deployment of the clip 202.

In another exemplary embodiment, as shown in FIGS. 17 and 18 , a device200′ is substantially similar to the device 200 described above exceptas described below. Rather than the wedge and cutting features of acapsule, as described above, however, first and second arms 204′, 206′of a clip 202′ of the device 200′ include features for wedging and/orcutting a suture 212′. The clip 202′ is substantially similar to theclip 202 described above except as distinguished below. The first arm204′, however, in addition to a notch 240′, a slot 210′ and a firstopening 244′, includes a second opening 250′ extending laterallytherethrough, proximally of the first opening 244′. The suture 212′ mayextend from a proximal end, through the flexible member and capsule 218′between the first and second arms 204′, 206′, until the suture 212reaches the second opening 250′. The suture 212′ may be passed from aninterior 242′ of the first arm 204′ through the second opening 250′ toan exterior 246′ of the first arm 204′ so that a portion of a length ofthe suture 212′ extends along the exterior '246′ of the first arm 204′between the second and first openings 250′, 244′. Upon reaching thefirst opening 244′, the suture 212′ is passed through the first opening244′ so that a distal loop 213′ of the suture 212′ may be hooked ontothe notch 240′.

The second arm 206′ includes, in addition to a suture receiving element208′, a wedge element 230′ extending laterally therefrom toward thefirst arm 204′ so that, when the clip 202′ is moved toward a lockedconfiguration, the wedge element 230′ extends through the first opening244′ against an edge thereof to wedge or pinch the suture 212′ betweenthe wedge element 230 and the edge of the first opening 244′. Upon beingmoved to the locked configuration, a distal edge 226′ of a capsule 218′cuts a portion of the suture 212′ extending between the first and secondopenings 244′, 250′. The device 200′ may be used in manner substantiallysimilar to the device 200, described above except as distinguishedbelow.

Although the device 200′ is described as including a wedging of thesuture 212′ via the wedge element 230′ and cutting of the suture 212′between the first and second openings 244′, 250′ via the distal edge226′ of the capsule 218′, in an alternative embodiment, the suture 212′may be cut in a manner substantially similar to the devices 100, 200described above. While the suture 212′ may be wedged between an edge ofthe first opening 244′ and the wedge element 230′, the suture 212′ maybe cut via a cutting feature along an interior of the capsule 218′.

A suture grabbing element and a slot or opening across which a loop of asuture extends may be formed in any of a variety of shapes andconfigurations, so long as a hook feature of the suture grabbing elementis able to pass through the slot or opening to hook the loop of thesuture. For example, in one embodiment, as shown in FIG. 19 , a clip 302may be substantially similar to the clips 202, 202′ described above.Rather than a substantially planar suture grabbing element receivedthrough a correspondingly shaped slot, a first arm 304 of the clip 302may include a substantially circular opening 310 extending therein,through a notch extending along an interior surface 342 of the first arm304. A suture grabbing element 308 extending laterally from a second arm306 of the clip 302 may be configured as a needle or wire including ahooked recess 336 extending therein.

In another example, as shown in FIG. 20 , a clip 402 may besubstantially similar to the clips 202, 302 describe above, comprisingfirst and second arms 404, 406. The first arm 404, however, includes asubstantially circular opening 410 extending laterally through a distalend 414 thereof. The notch, however, is configured as a slot 440extending proximally into the first arm 404 from a distal edge 414thereof, between an interior 442 and exterior surface 446 of the firstarm 404. Thus, when a suture loop is inserted into the slot 440, aportion of the loop extends across the opening 410. A suture grabbingelement 408 may be configured as a circular protrusion 409 extendinglaterally from a distal end 415 of the second arm 408 and including ahook 436 extending therefrom.

In an alternate embodiment, as shown in FIG. 21 , a device 500 comprisesa clip 502 substantially similar to the clips 202, 302, 402 describedabove except as distinguished below. The clip 502 includes first andsecond arms 504, 506 and the first arm 504, however, includes a slottedopening 510 open to a distal end 514 thereof. A notch is configured as asecond slot 540 extending proximally from and open to the distal end 514so that, when a suture loop is received within the second slot 540, aportion of the loop extends across the slotted opening 510. The secondarm 506 includes a suture grabbing element 506 extending laterallytherefrom, toward the first arm 508. The suture grabbing element 508 maybe substantially similar to the suture grabbing element 208 describedabove in regard to the device 200, including a hooking recess 538extending therein so that, when the first and second arms 504, 506 aredrawn toward one another, the suture grabbing element 508 extendsthrough the slotted opening 510 to hook the portion of the sutureextending thereacross.

As shown in FIGS. 22-27 , a device 600 according to another exemplaryembodiment may be substantially similar to the device 100 describedabove except as noted below, comprising a clip 602 including first andsecond arms 604, 606 movable relative to one another between an openconfiguration and a closed configuration and a needle 608 releasablycoupled to the first arm 604 to pass a suture 612 connected to theneedle 608 through a first portion of tissue along a first side oftissue opening. Although not shown, the clip 602 may be moved betweenthe open and closed configurations via a capsule in a mannersubstantially similar to that described above for the capsule 118.Similarly to the device 100, when the clip 602 is moved toward theclosed configuration over the first portion of tissue, the needle 608 ispassed through the first portion of tissue to engage with an engagingfeature 610 of the second arm 606 so that, when the clip 602 is movedonce again to the open configuration, the needle 608 is released fromthe first arm 604, leaving the needle 608 engaged with the second arm606. As the clip 602 moves to the open configuration, the suture 612 isdrawn through the first portion of tissue. The clip 602 is then openedand repositioned over a second portion of tissue (e.g., along a secondside of a tissue opening). Once the clip 602 has been repositioned asdesired, the clip 602 is moved to the closed configuration to grip thesecond portion of tissue between the first and second arms 604, 602. Thesuture 612 is then tensioned to draw the first portion of tissue,through which the suture 612 has been passed, toward the second portionof tissue, over which the clip 602 is clipped, until the first portionof tissue is drawn against the second portion of tissue, closing thetissue opening.

In this embodiment, the second arm 606 may be substantially rigid whilethe first arm 604 is pivotally coupled thereto to be moved relative tothe second arm 606 between the open and the closed configurations. Theneedle 608 is preloaded onto the first arm 604 and is coupled theretovia a releasable hinge 616 at an end thereof. The hinge 616 of theneedle 608 is received within a correspondingly shaped recess 617 alongan interior 642 of the first arm 604 via a snap fit which permits theneedle 608 to pivot about the hinge 616 when received within the recess617. The needle 606 may be curved along a length thereof and movablebetween a preloaded insertion configuration, as shown in FIG. 22 , and afiring position, as shown in FIG. 23 . In particular, when the hinge 616is engaged with the recess 617, the needle 608 pivots about the hinge616 at a first end 620 of the needle 608 so that a second end 622 of theneedle 608 may be moved from the preloaded insertion configuration, inwhich the second end 622 extends toward the first arm 604, to a firingposition in which the second end 622 extends toward the second arm 606.Although the needle 608 is described and shown as being coupled to thefirst arm 604 via a hinge 616, the needle 608 may be releasably coupledto the first arm 604 in any of a variety of ways so long as the needle608 is pivotal relative thereto, as described above.

The second arm 606 includes the engaging feature 610 which may beconfigured as a longitudinal recess 654 extending through a portion ofthe second arm 606 along with restraining tabs 656 extending over aportion of the longitudinal recess 654 to prevent the needle 608 frombeing disengaged from the second arm 606 once the needle 608 is receivedwithin the longitudinal recess 654. The longitudinal recess 654 is sizedand shaped to receive the needle 608 and may include a curved surface658 for guiding the needle 608 thereinto as the clip 602 is moved towardthe closed configuration. Once the needle 608 has been received therein,the needle 608 is prevented from being disengaged therefrom via therestraining tabs 656.

Similarly to the devices 100, 200, the suture 612 may extend from aproximal end coupled to a handle assembly of the device 600, through aflexible member and capsule coupled to the clip 602 to a distal end 648connected to the needle 608. Similarly to the clip 202, the first arm604 may include an opening 644 through which the suture 612 may extendfrom the interior 642 of the first arm 604 to an exterior 646 of thefirst arm 604. In the preloaded insertion configuration, the suture 612extends along the exterior 646 about a distal end 614 of the first armto the distal end 648 connected to the needle 608, which is pivotallycoupled to the interior 642 of the first arm 604 via the hinge 616.

The device 600 may be used in a manner substantially similar to thedevice 100 described above. In particular, the clip 602 is inserted intoa living body to the tissue opening to be treated in the preloadedinsertion configuration shown in FIG. 22 . Upon reaching the tissueopening, the clip 602 is moved toward the open configuration such thatdistal ends 614, 615 of the arms 604, 606 are separated from oneanother. The needle 608 is then pivoted about the hinge 616 to thefiring position, shown in FIG. 23 , by tensioning the suture 612connected thereto (i.e., drawing the suture 612 proximally relative tothe clip 602) so that the second end 622 of the needle 608 extendstoward the second arm 606. The clip 602 is positioned adjacent to thefirst portion of tissue with the first portion of tissue is receivedbetween the second end 622 of the needle 608 and the second arm 606.Once the clip 602 is positioned over the first portion of tissue, asdesired, the clip 602 is moved toward the closed configuration such thatthe needle 608 is moved toward the second arm 606, piercing the firstportion of tissue and sliding into the longitudinal recess 654 of thesecond arm 606. As the needle 608 is received within the longitudinalrecess 654, the needle 608 comes into contact with the curved surface658 thereof, as shown in FIG. 24 , to be guided along a length thereof.Thus, the needle 608 pivots about the hinge 616 as the needle 608 isreceived proximally through the longitudinal recess 654, as shown inFIG. 25 .

When the needle 608 is received within the longitudinal recess 654, therestraining tabs 656 lock the needle 608 therein such that the needle608 cannot be disengaged from the second arm. A force of the engagementbetween the needle 608 and the restraining tabs 656 is greater than aforce of the engagement between the hinge 616 and the recess 617 so thatmoving the clip 602 toward the open configuration causes the hinge 616to be disengaged from the first arm 604 while the needle 608 remainslocked to the second arm 606, as shown in FIGS. 26 and 27 . Thus, as theclip 602 is moved toward the open configuration, the suture 612 is drawnthrough the first portion of tissue.

After passing the suture 612 through the first portion of tissue, theclip 602 is positioned adjacent to the second portion of tissue,creating slack in the suture 612 as the clip 602 is moved to a desiredposition relative to the second portion of tissue. When the secondportion of tissue has been received between the first and second arms604, 606, the clip 602 may be moved toward the closed configuration togrip the second portion of tissue therebetween. Similarly to the devices100, 200 described above, the suture 612 may then be tensioned to drawthe first portion of tissue toward the second portion of tissue, therebyclosing the tissue opening. The clip 602 may be locked in the closedconfiguration, similarly to the clips 102, 202 described above in regardto the devices 100, 200. Locking the clip 602 in the closedconfiguration may wedge and cut the suture 612 via, for example, a wedgeand cutting feature along an interior of the capsule, so that the clip602 and a distal portion of the suture 612 may be deployed within thebody.

As shown in FIG. 28 , a device 700 according to another exemplaryembodiment may be substantially similar to the device 600 describedabove except as discussed below. Rather than being coupled to a firstarm 704 of a clip 702 via a hinge, however, a needle 708 of the device700 is coupled to the first arm 704 via tabs 716 extending therefrom andengaged within correspondingly shaped slots 717 in the first arm 704.The tabs 716 and corresponding slots 717 are configured to permitmovement (e.g., pivoting) of the needle 708 relative to the first arm704 similarly to the device 600 described above. The tabs 716 remainengaged with the slots 717 until the needle 708 is received within theengagement feature along a second arm (not shown) of the clip 702.

As shown in FIGS. 29-30 , a device 800 may be substantially similar tothe device 600 described above except as discussed below. A second arm806 of a clip 802 of the device 800, however, includes an engagementfeature 810 that further includes an elastic member 860 in addition to alongitudinal recess 854 and retaining tabs 856. The elastic element 860extends within the longitudinal recess 845 and may be configured as aleaf spring. In particular, the elastic element 860 is biased in captureconfiguration in which the elastic member 860 extends into thelongitudinal recess 854. Thus, when a needle, which may be substantiallysimilar to any of the needles described herein (e.g., needle 608, needle708) extends into the longitudinal recess 854, the elastic element 860is deflected to permit the needle to be received therein. Once theneedle is received within the longitudinal recess 854, the elasticelement 860 reverts toward the biased configuration to retain the needlein the longitudinal recess 854 by pushing the needle against theretaining tabs 856.

According to another example, as shown in FIG. 31 , a device 900 may besubstantially similar to the devices 600-800 described above except asdiscussed below. A needle 908, however, may be pivotally coupled to afirst arm 904 of a clip 902 via a C-Shaped connector 916 at an end ofthe needle 908, which is mounted over a pin 917 extending across adistal portion of the first arm 904. The C-shaped connector 916 and thepin 917 together create a hinge mechanism so that the needle 908 may bepivoted about the pin 917 between a preloaded insertion configurationand a firing position, as described above in regard to the device 600.The C-shaped connector 916 also permits the needle 908 to disengage thefirst arm 904, once the needle engages an engagement feature 910 of thesecond arm 906.

A device 1000, as shown in FIG. 32 , may also be substantially similarto the devices 600-800 except as discussed below and comprises a clip1002 including first and second arms 1004, 1006. A needle 1008 iscoupled to the first arm 1004, however, via a ball-shaped connectors1016 at an end thereof, which are received within corresponding shapedrecess 1017 within the first arm 1004. The ball-shaped connectors 1016permit the needle 1008 to pivot with respect to the first arm between apreloaded insertion configuration and a firing position. Although theabove embodiments of the devices 600-1000 describe particular examplesof a pivotal connection between a needle and an arm of a clip, theneedle may be connected to the arm in any of a number of different waysso long as the needle is releasably coupled to the arm and permits apivotal motion of the needle relative to the arm.

While embodiments have been described above, a number of modificationsand changes may be made without departing from the scope of thedisclosure. Thus, it is intended that the present disclosure covermodifications and variations provided that they come within the scope ofthe appended claims and their equivalents.

1-20. (canceled)
 21. A tissue clipping device for treating a tissueopening, comprising: a first arm pivotally coupled to a second arm, thefirst arm including a tissue penetrating element extending from thefirst arm toward the second arm, wherein the first and second arms aremovable relative to one another between an open configuration, in whichdistal ends of the first and second arms are separated from one anotherto receive tissue therebetween, and a closed configuration, in which thedistal end of the first arm is moved toward the distal end of the secondarm to grip the tissue, the second arm including a receiving featureconfigured to releasably receive the tissue penetrating element when thefirst and second arms are brought into the closed configuration; and asuture including a loop at a distal end thereof, the suture extendingthrough the device to engage, in an initial configuration, a second armsuture linking feature of the second arm and wherein the first armincludes a first arm suture linking feature including a hook configuredso that, when the first and second arms are brought from the openconfiguration to the closed configuration with the loop in the initialconfiguration, the hook grabs the loop so that, upon subsequent movementof the first and second arms to the open configuration, the loop ispulled by the hook out of engagement with the second arm.
 22. The deviceof claim 21, wherein the tissue penetrating element is configured topenetrate tissue received between the first and second arms when thefirst and second arms are drawn into the closed configuration and topull out of the penetrated tissue when the first and second arms aresubsequently moved to the open configuration drawing the suture throughthe penetrated tissue.
 23. The device of claim 21, wherein the receivingfeature includes a first opening extending through the second armpositioned so that, when the first and second arms are moved to theclosed configuration, the tissue penetrating element projects throughthe first opening.
 24. The device of claim 23, wherein the second armsuture linking feature includes a pair of projections on opposite sidesof the first opening, each of the projections including a loop holdingdistal surface around which the loop can be positioned.
 25. The deviceof claim 24, wherein the tissue penetrating element includes a radiallyouter surface angled so that, when the first and second arms are drawntogether into the closed configuration, the radially outer surfaceengages the loop so that the loop passes around a distal surface of thetissue penetrating element to engage the second arm suture linkingfeature.
 26. The device of claim 25, wherein the second arm suturelinking feature includes a slot extending into the tissue penetratingelement from the distal surface thereof.
 27. The device of claim 26,wherein the second arm suture linking feature further comprises a hookedrecess at a proximal end of the slot.
 28. The device of claim 24,wherein the second arm includes a second opening therein and wherein, inthe initial configuration, the loop extends from the projectionsproximally to pass through the second opening to an outer surface of thesecond arm.
 29. The device of claim 28, further comprising a capsulewithin which the first and second arms are slidable so that, when thefirst and second arms are drawn proximally into the capsule, contactbetween the capsule and the first and second arms draws the first andsecond arms together to the closed configuration, wherein the sutureextends proximally from the second opening into the capsule.
 30. Thedevice of claim 29, wherein the first and second arms are biased towardthe open configuration so that, when the first and second arms areextended distally from the capsule, the distal ends of the first andsecond arms move apart from one another under a natural bias of thefirst and second arms to the open configuration.
 31. The device of claim30, further comprising a flexible member extending proximally from thecapsule to an actuator configured to remain outside a living bodyaccessible to a user during use of the device.
 32. The device of claim25, wherein each of the projections of the second arm suture linkingfeature includes a slot extending proximally thereinto from a distalopening, the slot of each of the projections extending to a notch formedat a proximal end thereof.
 33. The device of claim 21, wherein thereceiving feature is formed as a slot extending proximally into thesecond arm from a distal opening.
 34. A method for treating a tissueopening, comprising: inserting to a target area within a patient body, adevice including first and second coupled to one another, the devicebeing inserted to the target area in a closed configuration, in which adistal end of the first arm is drawn toward a distal end of the secondarm; when the device reaches the target area, moving the device to anopen configuration in which the distal ends of the first and second armsare separated from one another; positioning the device so that a firsttarget portion of tissue is received between the distal ends of thefirst and second arms; drawing the distal ends of the first and secondarms to the closed configuration so that a tissue penetrating element ofthe first arm passes through the first target portion of tissue and thetissue penetrating element is releasably received in a receiving featureof the second arm and so that a loop of suture held by the second arm isengaged by a suture linking feature of the first arm; and moving thedevice to the open configuration so that the loop is pulled out ofengagement with the second arm and so that the tissue penetratingelement and the suture are pulled through the first target portion oftissue.
 35. The method of claim 34, further comprising: after the loopand the tissue penetrating element have been pulled through the firsttarget portion of tissue, moving the device to position the distal endsof the first and second arms adjacent to a second target portion oftissue on a side of a tissue opening opposite the first target portionof tissue; moving the device to the closed configuration to push thetissue penetrating element and the loop through the second targetportion of tissue; and drawing the suture proximally to pull the tissueopening closed.